AMA Expands Scope Campaign Against CAM Fields, Others; Nurses Blast "Medical McCarthyism"
Written by John Weeks
AMA Expands Scope Campaign Against CAM Fields, Others; Nurses Blast "Medical McCarthyism"
Summary: At the November Interim Meeting of the AMA House of Delegates, delegates considered two resolutions expanding the reach of the AMA Scope of Practice Partnership. One related to "oversight of mid-level providers" and the other regarded interpretation of diagnostic tests. The American Association of Nurse Anesthetists says AMA action "smacks of McCarthyism." AMA, which has not had nine distinct resolutions on SOPP issues, has placed the SOPP in its strategic plan.
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The list of targets of the American Medical Association's Scope of Practice Partnership appears to have grown with action proposed for the November 2006 AMA House of Delegates Meeting. (See list of prior Integrator articles on the topic, below.)
Resolution 902 (see full language below) asserts that it will be AMA policy "that state medical boards shall have full authority to
regulate the practice of medicine by all persons within a state notwithstanding
claims to the contrary by boards of nursing, mid-level practitioners or other
entities." The AMA will seek to find licensing board members in each state who will seek to actively prosecute others. Introduced by the American Society of Anesthesiologists.
Resolution 904 (see full language below) clarified that "the diagnosis of disease and diagnostic interpretation
of a study or studies for a specific patient constitutes the practice of
medicine." One target is expansion of scope by PhD researchers. The AMA will work to insure that Medicare fee schedules do not reimburse independent practices. Introduced by the College of American Pathologists and the American Society of Anesthesiologists.
Prior to the meeting of the House, the American Association of Nurse Anesthetists (AANA), a 36,000 member group, filed lengthy comments urging the House to not pass either of the two Resolutions. The AANA points to the lack of hard data behind the AMA SOPP assertions of harm caused by non MD/DO practitioners, charging that the AMA effort "smack of McCarthyism."
"[Resolution 902] states that 'some' 'mid-level or limited license practitioners'
continue to 'attempt to practice medicine' and 'rely on false assertions of
authority, not backed up by scope of practice laws, by various nursing boards
and other bodies regulating limited license practitioners ….'
"How many practitioners
constitute 'some' practitioners?
Two? A dozen? Five hundred?
How are such practitioners 'attempting' to practice medicine? What are the so-called 'false assertions' of
authority by various regulatory boards to which the resolution is
referring? These sweeping statements,
unsupported by evidence, smack of McCarthyism
-- arousing fears to instigate a witch hunt despite the lack of substantial
evidence justifying the action. [Bold added.] In fact,
when no evidence exists to support a claim, accusers often use broad, sweeping
claims that force the accused to discredit the claims even though there is no
evidence to support the claim in the first place. We assume the AMA does not want to be known
for making policy based on witch-hunt logic or McCarthyistic tactics."
The charge of McCarthyism is made repeatedly in the AANA response. The AANA refers to the AMA's plans to "reform boards of medicine to accomplish political objectives unrelated to patient safety." These will encourage "self-appointed McCarthy posses to
secure MD and DO scope of practice, in the absence of evidence supporting such
extraordinary actions."
[AMA's Resolutions promote] ... "self-appointed McCarthy posses to
secure MD and DO scope of practice, in the absence of evidence supporting such
extraordinary actions."
The AANA levels that same charge on Resolution 904, that action "is not built on evidence but instead on erroneous or flawed premises." They further state that
"the diagnosis of disease and diagnostic interpretation of a study or studies is
not exclusive to the practice of medicine (as Resolution 904 asserts), and is commonly a part of the scope
of practice of other professions as well."
The AANA concludes by stating that the AMA appears to be "taking the path of confrontation rather than constructive dialogue." States the AANA: "It is beyond time for us to focus on the “what”
of healthcare (the healthcare practices that will improve care) rather than
“who” provides healthcare (the type of provider delivering the care)." The AANA offers to meet with the AMA to work out any substantive issues. Full comments of the Nurse Anesthetists can be accessed here.
SOPP Listed in AMA Strategic Plan
The AMA's Scope of Practice Partnership, which, with 902 and 904, now embraces nearly a dozen separate resolutions (see list below), is formally a part of the AMA's published strategic plan. The language, on page 4 of that document, reads:
"Scope of Practice
"Our AMA will take a lead role in
coordinating medicine’s response to proposed scope expansions that are not
warranted by non-physicians’ education, training or experience. The Scope of Practice Partnership (SOPP)
provides a foundation for these activities.
"As we gain experience and traction
with the SOPP, we anticipate formation of rapid response coalitions that cross
specialty groups. We will consider
creation of state-level joint review committees, supported in part by a
compendium comparing education, licensure, etc. for different types of
practitioners. We will also seek data to
map the geographic distribution of various practitioner types in order to
inform discussion of access to care."
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(Note: The language of these Resolutions was for their submission to the House of Delegates prior to the November 2006 Interim Meeting. I was not able to verify that they were passed in precisely this form prior to publication of this article. These Resolutions can be accessed throughclicking here.)
AMA House of Delegates Resolution 902
Need for
Active Medical Board Oversight
of Medical Scope-of-Practice Activities by Mid
Level Practitioners
Introduced by: American
Society of Anesthesiologists
Referred to: Reference
Committee L
(H.
David Bruton, MD, Chair)
Whereas, Quality medical care requires appropriate
education, skills, training and experience, as recognized and established by state
laws; and
Whereas, As physicians, Medical Doctors (MDs) and Doctors of
Osteopathy (DOs) are the only persons fully licensed by the states to practice
medicine; and
Whereas, Some mid-level or limited license practitioners
continue to attempt to practice medicine and rely on false assertions of
authority, not backed up by scope of practice laws, by various nursing boards
and other bodies regulating limited license practitioners; and
Whereas, The quality of care rendered by individuals with
limited licenses is not equivalent to that of a physician (MD or DO); and
Whereas, Patients may be put at risk for injury or death by
receiving care from persons who are not physicians (MD or DO), but who claim to
be able to render medical care under the pretense that such conduct is allowed
by their respective state board or similar entity; and
Whereas, State-based regulation and licensure of medicine
should be aggressively protected to ensure patient safety and optimal clinical
outcomes; and
Whereas, Some state medical boards have asserted that they
lack jurisdiction over limited license practitioners who claim to act under the
authority of boards or entities other than the state medical board, even though
the conduct of such limited license practitioners would otherwise amount to the
practice of medicine without a license; and
Whereas, The Federation of State Medical Boards (FSMB)
established the Special Committee on Scope of Practice in July 2003, charged
with making decisions about changes in scope of practice for non-physician
practitioners, but it has declined to assist in prosecuting cases of medical
practice by limited license practitioners operating under claims of authority
by limited license boards and similar entities; and
Whereas, A unified response by organized medicine is needed
to counter the inability or unwillingness of state medical boards and the FSMB
to halt the unlicensed practice of medicine; and
Whereas, Our AMA and the Scope of Practice Partnership are
uniquely positioned and well qualified to address this matter of extreme
urgency so that our state laws and regulations can be upheld and the authority
of state medical boards can be re-established as having full jurisdiction,
oversight and authority over medical scope-of-practice activities by mid-level
practitioners; therefore be it
RESOLVED, That it shall be the policy of our American
Medical Association that state medical boards shall have full authority to
regulate the practice of medicine by all persons within a state notwithstanding
claims to the contrary by boards of nursing, mid-level practitioners or other
entities (New HOD Policy); and be it further
RESOLVED, That our AMA, through the Scope of Practice
Partnership, work jointly with state medical boards to assist law enforcement
authorities in the prosecution of unlicensed medical practice by limited or
mid-level practitioners (Directive to Take Action); and be it further
RESOLVED, That our AMA, through the Scope of Practice
Partnership, immediately embark on a campaign to identify and have elected or
appointed to state medical boards physicians (MDs or DOs) who are committed to
asserting and exercising their full authority to regulate the practice of
medicine by all persons within a state notwithstanding efforts by boards of
nursing or other entities that seek to unilaterally redefine their scope of
practice into areas that are true medical practice. (Directive to Take Action)
Fiscal Note: Implement accordingly at estimated staff cost
of $10,836.
AMA House of Delegates Resolution 904 - Received 9/25/06
Diagnosis
of Disease and Diagnostic Interpretation of Tests
Constitutes Practice of Medicine
to be Performed by or Under
the Supervision of Licensed Physicians
Introduced by: College
of American Pathologists
American
Society of Anesthesiologists
Referred to: Reference
Committee L
(H.
David Bruton, MD, Chair)
Whereas, There is a growing trend of non-physician personnel
seeking to expand their scopes of work into functions that traditionally
constitute the practice of medicine; and
Whereas, The diagnosis of disease constitutes the practice
of medicine and requires the integration of the interpretation of a study or
studies with clinical experience and training; and
Whereas, Laboratory personnel, including PhD scientists, are
increasingly involved in the implementation of new laboratory technologies that
require specialized training and education to perform such study or studies,
but such training and education does not induct the ability to make a
diagnostic interpretation for a specific patient; and
Whereas, Specialty societies representing non-physician
laboratory personnel and PhD scientists are advocating for expansion of their
scope of work into independent practice in the clinical setting and recognition
through payment under the physician fee schedule; and
Whereas, Our AMA has long recognized that quality medical
care requires appropriate education, skills, training and experience, as
recognized and upheld in state laws; and
Whereas, AMA Policy H-35.988 furthers the public interest in
quality medical care by opposing enactment of legislation to authorize the
independent practice of medicine by any individual who has not completed the
state's requirements for licensure to engage in the practice of medicine and
surgery in all of its branches; and
Whereas, AMA Policy H-35.973 supports the formulation of
clearer definitions of the scope of practice of physician extenders to include
direct appropriate physician supervision and recommended guidelines for
physician supervision to ensure quality patient care; and
Whereas, AMA Policy H-35.993 opposes any legislation or
program that would provide for Medicare payments directly to physician
extenders, or payment for physician extender services not provided under the
supervision and direction of a physician; therefore be it
RESOLVED, That it shall be the policy of our American
Medical Association that the diagnosis of disease and diagnostic interpretation
of a study or studies for a specific patient constitutes the practice of
medicine (New HOD Policy); and be it further
RESOLVED, That it shall be the policy of our AMA that a PhD
scientist or other non-physician laboratory personnel work under the
supervision or in collaboration with a physician under their applicable scopes
of work to perform a study or studies that will be the basis of a diagnostic
interpretation for a specific patient (New HOD Policy); and be it further
RESOLVED, That it shall be the policy of our AMA that the
Medicare physician fee schedule compensate only authorized persons for the
diagnostic interpretation of a specific patient and should not provide payments
directly to non-physician personnel working under the supervision or in
collaboration of a physician to perform a laboratory study or studies (New HOD
Policy); and be it further
RESOLVED, That our AMA pursue all appropriate legislative,
regulatory and legal actions through the Scope of Practice Partnership to
counter expansions of the scope of work by PhD scientists and other
non-physician laboratory personnel to authorize the independent practice of
medicine by any individual who has not completed the state's requirements for
licensure to engage in the practice of medicine. (Directive to Take Action)
Fiscal Note: Implement accordingly at estimated staff cost
of $1,929.
Received: 9/25/06
RELEVANT AMA POLICY
H-35.973 Scopes of Practice of Physician Extenders
Our AMA supports the
formulation of clearer definitions of the scope of practice of physician
extenders to include direct appropriate physician supervision and recommended
guidelines for physician supervision to ensure quality patient care. (Res. 213,
A-02) H-35.988 Independent Practice of Medicine by
"Nurse Practitioners"
The AMA, in the public
interest, opposes enactment of legislation to authorize the independent
practice of medicine by any individual who has not completed the state's
requirements for licensure to engage in the practice of medicine and surgery in
all of its branches. (Sub. Res. 53, I-82; Reaffirmed: A-84; Reaffirmed: CLRPD
Rep. A, I-92; Reaffirmed: BOT Rep. 28, A-03) H-35.993 Opposition to Direct Medicare Payments for
Physician Extenders
Our AMA reaffirms its
opposition to any legislation or program which would provide for Medicare
payments directly to physician extenders, or payment for physician extender
services not provided under the supervision and direction of a physician. (CMS
Rep. N, I-77; Reaffirmed: CLRPD Rep. C, A-89; Reaffirmed: Sunset Report, A-00) D-35.990 Limiting the Scope of Practice of Specialist
Assistants in Radiology
Our AMA supports the efforts
of the AmericanCollege of Radiology and will work with the Scope of Practice
Partnership and interested Federation partners to obtain regulation or
legislation which would preclude a Specialist Assistant in Radiology or other
non-physician practitioner from rendering an official report of any image
produced by any diagnostic imaging technique. (Res. 219, A-06) D-35.991 Licensure of Naturopaths
Our AMA will work through the
Scope of Practice Partnership and interested Federation partners to oppose the
licensure of naturopaths and report back to the House of Delegates at the 2006
Interim Meeting. (Res. 209, A-06) D-35.992 Need to Expose and Counter Nurse Doctoral Programs
(NDP) Misrepresentation
Our AMA will: (1) work jointly
with state attorneys general to identify and prosecute those individuals who
misrepresent themselves as physicians to their patients and mislead program
applicants as to their future scope of practice; (2) pursue all other
appropriate legislative, regulatory and legal actions through the Scope of
Practice Partnership, as well as actions within hospital staff organizations,
to counter misrepresentation by nurse doctoral programs and their students and
graduates, particularly in clinical settings; and (3) work with all appropriate
entities to ensure that all persons engaged in patient contact be clearly
identified either verbally, or by name badge or similar identifier, with regard
to their professional licensure in order that patients are aware of the
professional educational background of that person. (Res. 211, A-06)
D-35.999 Non Physicians’ Expanded Scope of Practice
(Laboratory Testing and Test Interpretation)
Our AMA, through appropriate
legislative and regulatory efforts, seeks to: (1) ensure that diagnostic
laboratory testing should only be performed by those individuals who possess
appropriate clinical education and training, under the supervision of licensed
physicians (MD/DO); and (2) limit laboratory test ordering and interpretation
of test results solely to licensed physicians (MD/DO) and licensed dentists
(DDS/DMD). (Sub. Res. 307, A-00)
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